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The Joint Commission (“TJC”) recently approved guidance revising its requirements regarding the time frame to evaluate a licensed practitioner’s ability to provide care, treatment, and services. The time frame for evaluation has changed from a period not to exceed two (2) years to a period not to exceed three (3) years unless law and regulation require a shorter period. It should be noted that Maine law imposes no specific time frames for the credentialing of practitioners.

In announcing this change, TJC explained that its goal was better alignment with the standard practice of evaluating licensed practitioners every three years. The revisions, which became effective immediately, apply to TJC-accredited ambulatory care organizations, behavioral health care and human services organizations, critical access hospitals, hospitals, nursing care centers, and office-based surgery practices.

For those hospitals that are not accredited by TJC or another organization, but have opted to follow its requirements regarding credentialing, the new guidance supports enlarging the credentialing time frame to three (3) years.

These extended medical staff credentialing timeframes should save TJC-accredited hospitals and critical access hospitals considerable administrative overhead and reduce the burden, time and costs associated with such credentialing.

For those facilities that are TJC-accredited, the new guidance can be found in Joint Commission Perspectives, December 2022, Volume 42, Issue 12.

Should you have questions, please contact Taylor Fawns at (207) 621-4390, or via email at

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